Ninety percent of patients who have back pain caused by a ruptured disk improve spontaneously with time, or bed rest, or chiropractic care, or physical therapy. Ten percent require surgery because of intractable pain and/or leg muscle weakness and/or bladder, bowel, or sexual dysfunction from progressive nerve pressure damage.

The goal of surgery is to stop the progression of any nerve damage, and to relieve the pain. It is successful in eighty percent of the cases, and it may take days, weeks, or months to improve, depending upon the length of time it persisted, and the amount of damage. Pain is subjective, and there is much less urgency than when leg muscle nerve damage is apparent, and much more urgent with bladder, bowel or sexual dysfunction.

This 32-year-old male patient injured his back bending over at work on 1/28. He came under the care of a chiropractor, Dr. #1, on that day and was seen every few days with "adjustments," and usually electrical techniques. He initially began to improve and feel better.

However, on 3/8 there was muscle weakness in the right lowered leg with planter flexion (foot down) and dorsiflexion (foot up) positions. Also, the reflexes in that leg were diminished. Dr. #1 noted: "recommend see M.D.", and noted Dr. #2 was his physician.

On 3/10 he saw Dr. #2 who noted that same history of injury, improvement with chiropractic care but worsening of his pain and weakness in his foot. He found normal reflexes. He concluded properly that he probably had a herniated (ruptured: extruded) disk and: "We will set him up for some P.T. (physical therapy) since he is extremely anxious to avoid surgery." Then, an MRI would be done if P.T. did not help.

On 3/13 the patient called and changed his mind, and wanted an MRI, and: "He is wetting the bed and has incontinence." The MRI was done that same day and showed: "L4-5 Disk Level: Degenerative disk disease with moderate-sized central and right paracentral disk extrusion which posteriorly displaces and impression pushes on the right L5 nerve root in the central canal. There is very mild encroachment of the central canal and mild encroachment of the proximal right and left neural foramina." This means there was a ruptured disk that was squashing the nerve root at that level on the right side. That was causing his symptoms. There was a smaller ruptured disk at the L5-S1 (next level), but was not causing nerve compression.

On 3/16 Dr. #3, a Neurosurgeon, saw the patient, noted all of the above and: "I recommended surgery because of his worsening neurological deficit." I agree.

That operation, a hemilaminectomy (cutting out a piece of the spine), diskectomy (removing the ruptured disk), and foraminotomy (enlarging the bony canal through which that nerve root passed), at the L4-5 level on the right side, was properly done under general anesthesia on 3/20. The Pathologist confirmed the bone and disk specimens were removed. The x-ray control identified the anatomical location. Prophylactic (preventative) antibiotics and compression bandages plus the anticoagulant Heparin (blood thinner) were used to prevent thrombophlebitis (clots forming in his leg veins).

All that hospital care was excellent. The Nurse's notes documented the patient's complaints of leg weakness, and numbness that pre-existed the operation. After surgery he was voiding (urinating) normally, and had less pain.

Dr. #3 saw him on 3/30, removed the skin staples, and noted he was healing normally but that: "He is still in a lot of pain." I have no further records.

The hospital consent signed by this patient noted he was advised of all the risks, complications, and alternatives, and "no guarantees have been made to me as to the result of the procedures."

Dr. #1 did standard chiropractic care, there was some improvement, and then a sudden worsening which he recognized, and referred the patient to a medical doctor. That is good care. The disk was ruptured when he bent over at work and not by Dr. #1. Massive force would have to be applied, similar to an automobile accident, to cause a disk to rupture by tearing the spinal ligaments. And massive force would be needed to make the situation worse, and would tear the muscles as well.

Therefore, I conclude that the Chiropractor gave good care and, unfortunately, based on the extent of the disk protrusion, not seen on a plain x-ray, it irritated that nerve root causing further symptoms that required urgent surgery which took place, after the patient changed his mind when he became incontinent of urine, five days after his last treatment by the Chiropractor.

This patient was 38 years old when he sustained a motor vehicle accident on September 22. In this accident, the patient was stopped when he was rear-ended and sustained neck trauma. The patient was evaluated at a local Emergency Ward and was released with a diagnosis of a neck strain with soft-tissue damage.

On September 24, he was evaluated by Dr. #1 of the Chiropractic Clinic. Dr. #1 knew, or should have known, that this patient's past history included rheumatoid arthritis and a cervical (neck) fusion with bone grafts and metal screws in 1995. Dr. #1 obtained spine radiographs on this initial visit and also recommended Chiropractic therapy including Sine Wave Therapy, Intersegmental Traction and others. He was examined at this Clinic on September 27, October 1, October 4, October 7, October 11, October 13, October 18 and on October 20. On virtually every occasion, Dr. #1 recommended and apparently performed Chiropractic manipulation which often included cervical (neck) intersegmental traction. Available records document that these Chiropractic manipulations had a limited effect on the patient's symptoms and appear to have actually aggravated the neck and shoulder pain.

It can be stated, within a reasonable degree of medical certainty, that the presence of a cervical fusion procedure and chronic neck arthritic pain may be aggrevated by Chiropractic manipulation. As such, it was the responsibility of Dr. #1 to inform his patient of the inherent risks of the cervical traction and manipulation procedures which included exacerbation of chronic neck pain. The absence of such informed consent constituted a deviation from existing standards of medical care.

However, from available records, it is impossible to attribute this deviation from existing standards to the proximate cause of his persistent neck pain symptoms. This is due to documentation of other possible causes including trauma, rheumatoid arthritis, spondylosis, and the patient's own admission that he has spinal cord narrowing and degenerative disc disease (details and documentation might be very useful in these latter two instances).

Based upon the information in the records provided, it is anticipated that obtaining Expert opinions supporting the issue of negligence in this case will not be difficult.

However, associating this negligent action with the patient's current and persistent neck symptoms will be very problematic for the reasons listed above.